Anxiety and depression in surgeons: A systematic review.

INTRODUCTION: The unique pressures of a surgical career put surgeons at particular risk of mental health conditions, including anxiety and depression. Surgeons have previously been shown to have a high prevalence of psychological distress. This study aimed to systematically review the prevalence of anxiety and depression amongst surgeons, and to identify factors that can modify the risk of anxiety and depression in surgeons. METHODS: A 10-year systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines to identify citations related to the keywords "anxiety" OR "depression" AND "surgeon" in PubMed/Medline and ScienceDirect databases. Inclusion and exclusion criteria were applied to produce a final list of citations. RESULTS: Thirty-one citations were included with a total of 11,399 participants. The median percentage of anxiety in surgeons was 20 with a range of 54.6%. While the median percentage of depression was 24 with a range of 59%. Risk factors associated with a higher risk of anxiety and depression include female gender, younger age, concurrent burnout, and occupational concerns regarding the COVID-19 pandemic. Protective factors include institutional support and a sense of social belonging. CONCLUSIONS: There was a high prevalence of anxiety and depression amongst surgeons over the past decade. It is imperative to develop strategies to mitigate the effect of anxiety and depression in surgeons.

Surgeons' personality, characteristics and presence of meaning in life.

BACKGROUND: Surgeons work long shifts and are frequently on call. Pressure to make quick and accurate decisions along with the responsibility of performing complex procedures contribute to surgeons' high stress-levels, anxiety and altered empathy level. We aimed to study surgeons' personality and meaning in life at two different centres. METHODS: General surgeons completed 47 questions. Visual analogous scale-items with controlled internal consistency (Cronbach alpha) coefficients varying from .77 to .85 were used from the following scales: Global Measure of Perceived Stress; Hostility Questionnaire; Jefferson Scale of Physician Empathy; Meaning in Life Questionnaire-SF; Rosenberg Self-Esteem Scale; Spielberger State Anxiety Scale and Quality of Work life Scale. Multiple linear regression analyses, parametric or non-parametric tests were employed when considered adequate. RESULTS: Fifty-four participants were recruited from 3 different levels of training. Gender differences in Anxiety, Physician Empathy and presence of meaning in life (MIL-P) were revealed. Junior trainees differed from senior trainees and consultants as regards MIL-P, Anxiety, Stress and work-related factors. The surgeons' self-rated self-esteem was work-related. Surgeons' Quality of Work Life was best predicted by Physician Empathy but also their self-rated Self-Esteem contributed significantly to the prediction. Surgeons' MIL-P was significantly predicted by Physician Empathy and State Anxiety. CONCLUSION: Surgeons' current personality attributes might not apply to all of them. Female surgeons were more empathetic and felt more presence of meaning in life than male surgeons, and men were less anxious than female surgeons. Junior trainees experienced less anxiety than senior trainees but were more stressed than consultants. The most significant predictors of surgeons' personality were their experience of presence of meaning in life along with their level of empathy.

General surgeons' occupational musculoskeletal injuries: A systematic review.

INTRODUCTION: Surgeons are expected to work long hours in operating theatres. A high prevalence of work-related musculoskeletal (WRMSK) injuries and pain in healthcare professions exists. We aimed to study WRMSK pain and injuries in general surgeons and study their risk in different surgical techniques comprising open, laparoscopic and robotic-assisted surgery. METHODS: A systematic search was performed in compliance with The PRISMA checklist. Search was performed in PubMed and Cochrane library databases for 6 years to 2024. The search terms used were "disability and surgeon", "occupational injuries and surgeon", and "musculoskeletal pain and surgeons", in addition to MESH terms in PubMed database. Risk of bias was calculated among studies. RESULTS: The search revealed 3648 citations from which a final list of 24 citations were included after application of inclusion and exclusion criteria. The citations comprised over 1900 surgeons including consultants and surgical trainees from different subspecialities. Incorporated citations consisted of 21 cross-sectional 3 observational studies. Most common pain sites, risks and preventative measure for MSK injuries were revealed. CONCLUSION: There is high prevalence of WRMSK pain among general surgeons. Surgeons were primarily affected at physical body parts ranging from the neck, shoulders, upper back and lower back to upper extremity. Robotic-assisted surgery led to lower post-operative discomfort and decreased demanding muscle activity in upper extremities but enhanced static neck position resulting in subjective back stiffness compared with laparoscopic surgery.

Surgeons with disabilities, they do exist.

INTRODUCTION: Doctors with disability are likely to face major life crises, challenges and distressing emotions from unforeseen circumstances that threaten their physical well-being. We aimed to identify the existence of work-related pain and discomfort that may cause surgeon's disability. Surgeons who were struck with unpredictable disasters leading to disabilities were also reviewed. METHODS: We conducted a 10-year literature review. In addition, citations about surgeons' physical disabilities were complemented with commentaries about disabled surgeons from gray literature. The quantitative citations were quality assessed by MERSQI scores and evidence graded according to GRADE. For the qualitative study part, the severely traumatized surgeons were analysed by means of Cullberg's crisis phases (CCP) and analysed from Tedeschi and Calhoun's post-traumatic growth perspective (PTG). RESULTS: Altogether 3593 citations from PubMed were studied, and 10 citations met inclusion criteria with a total of 11591 participants. We included 6 surgeons subjected to highly traumatic events complicating their medical career. Our quantitative citations' mean MERSQI score was 11.73 (SD .79) and the citations' evidence value completed grade II (moderate quality: 11.26 to 12.00 scores). Work-related musculoskeletal pain and occupational injuries may lead to physical disabilities. The accidentally traumatized surgeons fought through the four CCP phases and reached successfully the PTG stage. CONCLUSIONS: The surgical workforce is at high risk of work-related musculoskeletal morbidity which can progress to chronic pain and disruption of surgeon's career. Surgeons with disabilities faced serious barriers in their career. Institutions and healthcare systems must urgently develop support strategies for surgeons with disabilities.

Surgeon's narcissism, hostility, stress, bullying, meaning in life and work environment: a two-centered analysis.

INTRODUCTION: Disruptive physician behaviour can affect patients' safety. If surgical trainees throughout higher education experience disruptive behaviour, impaired work-life may follow. Therefore, we aimed to study surgeons' level of narcissism (N), hostility, and stress in relation to their work environment and potential experience of bullying. We also scrutinized search for or presence of meaning in life. METHODS: General surgeons in UK National Health Service from 2 hospitals participated with 3 levels of training: junior trainees (JT), senior trainees (ST), and consultants (CONS). Participants completed 52 VAS-formed questions plus demographics. Modified questionnaires were used for assessments of 'hostility', 'narcissism', meaning in life, quality of work-life, and bullying. RESULTS: Altogether 33% of surgeons displayed narcissism and 22% could exhibit disruptive behaviour. MANOVA significant differences between low, medium, and high narcissism groups were revealed in hostility (p<.01), perceived stress (p=.001), and presence of meaning in life (p<.05). Regression analyses explained hostility both by N-scale (p=.000) and 'being bullied during training'(p=.009) but negatively by 'presence of meaning in life'(p=.004). Surgeons' perceived stress was explained both by N-scale (p=.000) followed by 'seeing others bullied during training (p=.000) and negatively by 'working extra days beyond schedule' (p=.007). The presence of meaning in life was explained mostly by good beneficial stress (p= .000) but negatively both by 'doing extra work beyond schedule' (p= .016) and hostility (p= .003). CONCLUSION: Surgeons may exhibit disruptive behaviour in a challenging situation. The narcissim-scale was the best predictor of hostility and perceived stress. Being bullied during surgical training predicted hostility. Seeing others being bullied during surgical training predicted stress. Beneficial stress is explained best by surgeons' experience of the presence of meaning in life.

Abdominal hernia mesh repair in patients with inflammatory bowel disease: A systematic review.

BACKGROUND: Postoperative hernia-repair complications are frequent in patients with inflammatory bowel disease (IBD). This fact challenges surgeons' decision about hernia mesh management in these patients. Therefore, we systematically reviewed the hernia mesh repair in IBD patients with emphasis on risk factors for postoperative complications. METHOD: A systematic review was done in compliance with the PRISMA guidelines. A search was carried out on PubMed and ScienceDirect databases. English language articles published from inception to October 2021 were included in this study. MERSQI scores were applied along with evidence grades in agreement with GRADE's recommendations. The research protocol was registered with PROSPERO (CRD42021247185). RESULTS: The present systematic search resulted in 11,243 citations with a final inclusion of 10 citations. One paper reached high and 4 moderate quality. Patients with IBD exhibit about 27% recurrence after hernia repair. Risk factors for overall abdominal septic morbidity in Crohn's disease comprised enteroprosthetic fistula, mesh withdrawals, surgery duration, malnutrition biological mesh, and gastrointestinal concomitant procedure. CONCLUSION: Patients with IBD were subject, more so than controls to postoperative complications and hernia recurrence. The use of a diversity of mesh types, a variety of position techniques, and several surgical choices in the citations left room for less explicit and more implicit inferences as regards best surgical option for hernia repair in patients with IBD.

Acute surgical admissions at the end of life-an analysis of non-operative hospital deaths.

BACKGROUND: Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission. METHODS: This single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis. RESULTS: A total of 72 patients were included in this study, of which 68.1% died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p < 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death. CONCLUSION: Frailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.

Laparoscopic Surgery and the debate on its safety during COVID-19 pandemic: A systematic review of recommendations.

INTRODUCTION: The transmission of COVID-19 virus since the outbreak of viral pneumonia due to SARS-CoV-2 gave rise to protective operative measures. Aerosol generating procedures such as laparoscopic surgery are known to be associated with increased risks of viral transmission to the healthcare workers. The safety of laparoscopy during the pandemic was then debated. We aimed to systematically review the literature regarding the safe use of laparoscopy during COVID-19. METHODS: We performed a systematic search using PubMed and ScienceDirect databases from inception to 1st May, 2020. The following search terms were used: ''laparoscopic surgery and COVID-19''; ''minimally invasive surgery and COVID-19''. Search items were considered from the nature of the articles, date of publication, aims and findings in relation to use of laparoscopic surgery during COVID-19. The study protocol was registered with PROSPERO register for systematic reviews (CRD42020183432). RESULTS: Altogether, 174 relevant citations were identified and reviewed for this study, of which 22 articles were included. The analysis of the findings in relation to laparoscopic surgery during the pandemic were presented in tabular form. We completed the common recommendations for performing laparoscopy during the COVID-19 pandemic in forms of pre-, intra- and postoperative phases. CONCLUSION: There is no scientific evidence to date for the transmission of COVID-19 by laparoscopic surgery. Laparoscopy can be used with precautions because of its benefits compared to open surgery. If safe, conservative management is the primary alternative during the pandemic. We concluded that recommended precautions should be respected while performing laparoscopy during the pandemic.

The Application of a Performance-Based Self-Administered Intra-procedural Checklist on Surgical Trainees During Laparoscopic Cholecystectomy.

INTRODUCTION: Surgical checklists are in use to reduce errors for safer surgery. We aimed to study the effect of a previously designed performance-based self-administered intra-procedural checklist on the performance of trainees during elective laparoscopic cholecystectomy. METHODS: Twenty-four laparoscopic cholecystectomies were enrolled into the study. Six surgical trainees each performed four procedures, two without the checklist and directly followed by two procedures with the checklist. A soft beeping sound reminded each trainee to apply the checklist every 4 min during the procedures. The unedited videos were analysed using the human reliability analysis technique for the number of consequential errors, number of interventions by the trainer, number of instrument movements and time execution. The trainees' satisfaction was assessed on a 5-point Likert scale questionnaire. Nonparametric test was used for data analysis. p value was defined as significant when p < 0.05. RESULTS: Participants performed statistically better with the application of the checklist compared to when no checklist was used, respectively: Median [IQR] total number of errors 1.51 [0.80] versus 3.84 [1.42] (p = 0.002) and consequential errors 0.20 [0.12] versus 0.45 [0.42] (p = 0.005), and the number of instrument movements per time decreased from 11.90 [5.34] to 10.38 [5.16] (p = 0.04). With the introduction of the checklist, the number of interventions by the trainer per time decreased from 2.79 [1.85] to 0.43 [1.208] (p = 0.003). The trainees satisfaction score was 4.5 [1] for the first question, 4 [1] for the second question and 4 [2] for the third question. CONCLUSION: The self-administered intra-procedural checklist improved the performance of surgical trainees and decreased the number of interventions by the trainer during laparoscopic cholecystectomy. The trainees were generally satisfied using the checklist during the procedures.

A Comparative Study of Generic Visual Components of Two-Dimensional Versus Three-Dimensional Laparoscopic Images.

AIMS: There is a strong evidence to suggest that 3D imaging improves the laparoscopic task performance when compared against 2D. However, to date, no study has explained why that might be. We identified six generic visual components during laparoscopic imaging and aimed to study each component in both 2D and 3D environments for comparison. METHODS: Twenty-four consented laparoscopic novices performed specific isolated tasks in a laparoscopic Endo Trainer in 2D and 3D separately. The six endpoints were the accuracy in detecting changes in the laparoscopic images in the following components: distance, area, angle, curvature, volume and spatial coordinates. All the components except the spatial coordinates were assessed by creation, measurement and comparison. Each component was analysed between 2D and 3D groups and within each group at different values. Tests of spatial coordinates were video-recorded and analysed for error number and error types by human reliability analysis technique. Errors types included past-pointing, not reaching the object and touching the wrong object. The results were statistically analysed with independent T test. RESULTS: There was no statistically significant difference between 2D and 3D accuracy in the angle, area, distance and curvature. 3D performed more accurately in comparing volumes (p = 0.05). In spatial coordinates, there were a statistically significant higher number of errors in 2D as compared to 3D (p < 0.001). Past-pointing and touching the wrong objects were significantly higher in 2D (p < 0.05). CONCLUSION: Between all the visual components, detecting change in volume and the spatial coordinates showed significant improvement in 3D environment when compared to 2D.

The effect of a performance-based intra-procedural checklist on a simulated emergency laparoscopic task in novice surgeons.

Surgical checklists are in use as means to reduce errors. Checklists are infrequently applied during emergency situations in surgery. We aimed to study the effect of a simple self-administered performance-based checklist on the laparoscopic task when applied during an emergency-simulated scenario. The aviation checklist for unexpected situations is commonly used for simulated training of pilots to handle emergency during flights. This checklist was adopted for use as a standardised-performance-based checklist during emergency surgical tasks. Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into two equal groups; those using the checklist that was applied once every 20 s (checklist group) and those without (control group). The checklist group performed significantly better in 5 out of 7 technical factors when compared to the control group: right instrument path length (m), median (IQR) 1.44 [1.22] versus 2.06 [1.70] (p = 0.029), right instrument angular path (degree) 312.10 (269.44 versus 541.80 [455.16] (p = 0.014), left instrument path length (m) 1.20 [0.60] versus 2.08 [2.02] (p = 0.004), and left instrument angular path (degree) 277.62 [132.11] versus 385.88 [428.42] (p = 0.017). The checklist group committed significantly fewer number of errors in the application of haemostatic clips, 3 versus 28 (p = 0.006). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p = 0.724) and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p = 0.165). The performance-based intra-procedural checklist significantly enhanced the surgical task performance of novices in an emergency-simulated scenario.

Feedback in surgical education.

INTRODUCTION: The positive effect of feedback has long been recognized in surgical education. Surgical educators convey feedback to improve the performance of the surgical trainees. We aimed to review the scientific classification and application of feedback in surgical education, and to propose possible future directions for research. METHODS: A literature search was performed using Pubmed, OVID, CINAHL, Web of science, EMBASE, ERIC database and Google Scholar. The following search terms were used: 'feedback', 'feedback in medical education', 'feedback in medical training' and 'feedback in surgery'. The search was limited to articles in English. RESULTS: From 1157 citations, 12 books and 43 articles met the inclusion criteria and were selected for this review. CONCLUSION: Feedback comes in a variety of types and is an essential tool for learning and developing performance in surgical education. Different methods of feedback application are evolving and future work needs to concentrate on the value of each method as well as the role of new technologies in surgical education.

Robotic Appendicectomy: A review of feasibility.

Acute appendicitis is one of the most common abdominal emergencies. There has been an increasing use of robotic abdominal surgery. However, it remains underutilised in emergency settings. This study aimed to systematically review robotic appendicectomy (RA) feasibility. A 20-year systematic review was performed, along with quality assessment. The research protocol was registered with PROSPERO. The search yielded 1,242 citations, including 9 articles. The mean quality score was 10.72 ± 2.56. The endpoints across the studies were rate of conversion to open surgery, length of hospital stay, blood loss and operative time. RA is a safe, feasible technique that can be performed in elective and emergency settings with minimal blood loss. The operative time and hospital stay were within acceptable limits. Robotic surgery's major drawback is its high cost and limited availability. Future studies evaluating RA with a focus on its application during emergencies and its cost-effectiveness are recommended.

Racial discrimination in surgery: A systematic review.

INTRODUCTION: Racial/ethnic discrimination indicates the stereotyped or unkind conduct of superiority towards other persons based on their race or skin color. The UK General Medical Council published a statement supporting zero-tolerance approach to racism in the workplace. We aimed to systematically review racial discrimination in surgery and answer the following questions: (1) Does racial/ethnic discrimination in surgery exist in citations from the last 5 years. (2) If yes, are ways suggested to reduce racial/ethnic discrimination in surgery? METHODS: The systematic review was performed in compliance with the PRISMA guidelines along AMSTAR 2. A 5-year literature search was carried out on PubMed for articles published from 1/1/2017 to 01/11/2022. Search terms were 'racial discrimination and surgery', 'racism OR discrimination AND surgery', 'racism OR discrimination AND surgical education'. The retrieved citations were quality assessed by MERSQI and evidence graded by GRADE. RESULTS: A total of 9116 participants responded with a mean of 1013 (SD = 2408) responses per citations reported in 9 studies from a final list of 10 included citations. Nine studies were from USA and 1 from South Africa. There was evidence of racial discrimination in the last 5 years and the results were justified on strong scientific evidence constituting the basis for evidence grade I. The second question's answer was 'yes' which was defendable on moderate scientific recommendation and thereby establishing the basis for evidence grade II. CONCLUSION: There was sufficient evidence for the presence of racial discrimination in surgical practice in the last 5 years. Ways to decrease racial discrimination in surgery exist. Healthcare and training systems must increase the awareness of these issues to eliminate the harmful effect on the individual as well as on the level of the surgical team performance. The existence of the discussed problems must be managed in more countries with diverse healthcare systems.